Abnormal Uterine Bleeding · Dysfunctional uterine bleeding (DUB) Classification System PALM-COEIN...

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Abnormal Uterine Bleeding Dr. Brett Vair, MD FRCSC, Obstetrics & Gynecology 45 th Dalhousie Annual Spring Refresher Course March 8, 2019

Transcript of Abnormal Uterine Bleeding · Dysfunctional uterine bleeding (DUB) Classification System PALM-COEIN...

Page 1: Abnormal Uterine Bleeding · Dysfunctional uterine bleeding (DUB) Classification System PALM-COEIN (FIGO, 2011) ACOG Practice Bulletin No. 128: Diagnosis of Abnormal Uterine Bleeding

Abnormal Uterine

BleedingDr. Brett Vair, MD FRCSC, Obstetrics & Gynecology

45th Dalhousie Annual Spring Refresher Course

March 8, 2019

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Disclosure

• In the past, I have been a presenter with Bayer (2016)

• Mitigating potential bias:

• The content of this presentation is based on best practice

and evidence based medicine

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Outline

• Terminology and classification

• Clinical evaluation

• Laboratory investigations

• Imaging studies

• When should endometrial biopsy be considered?

• Overview of medical treatment

• Nonhormonal vs. hormonal options

• When is referral to Gynecology indicated?

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A common problem…

• Menstrual disorders are a common indication for medical

visits

• Heavy menstrual bleeding affects up to 30% of women in

their reproductive lifetime

• Significant impact on:

• Quality of life

• Time off work

• Health care system

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Definitions

AUB = Any variation from the normal menstrual cycle

• Includes changes in:

• Regularity and frequency of menses

• Duration of flow

• Amount of blood loss

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Definitions

• Heavy menstrual bleeding

• The most common complaint of AUB

• “Excessive menstrual blood loss which interferes with the

woman’s physical, social, and emotional, and/or material

quality of life”

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Terminology

Menorrhagia

Metrorrhagia

Dysfunctional uterine bleeding (DUB)

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Classification System

PALM-COEIN(FIGO, 2011)

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ACOG Practice Bulletin No. 128: Diagnosis of Abnormal Uterine Bleeding in Reproductive-

Aged Women. July, 2012

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Evaluation of AUB Laboratory Investigations

• Recommended investigations:

• CBC (II-2A)

• Urine or serum βhCG ((III-C)

• Cervical cancer screening

• Testing for Chlamydia trachomatis in patients at high risk

• TSH

• *Only if there are symptoms or findings suggestive of thyroid

disease (II-2D)

• Testing for coagulation disorders in women with risk factors(II-2B)

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Of all women presenting with heavy menstrual

bleeding, which percentage will ultimately be

found to have an underlying bleeding disorder?

A. 1%

B. 3-5%

C. 10-20%

D. 30%

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When should testing for bleeding

disorders be ordered?

• History of heavy, regular, cyclic periods since menarche

• Up to 50% of adolescents presenting with heavy bleeding at

menarche will have a coagulopathy

• Personal or family history of abnormal bleeding

• Recommended testing:

• INR, PTT

• Special testing for Von Willebrand’s disease (factor VIII

level, vWF antigen, and vWF functional assay)

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• There is no evidence for routine measurement of:

• Ferritin

• TSH if there is no reason to suspect thyroid disease

• FSH, LH

• Estradiol

• Progesterone

Evaluation of AUB Laboratory Investigations

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• Imaging studies may be indicated when:

• History or physical exam suggests structural causes

• There is a risk of malignancy

• Conservative management has failed

Evaluation of AUB Imaging Studies

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• Transvaginal ultrasound should be the first line imaging

modality for investigation of AUB (I-A)

• Assists with diagnosis of:

• Endometrial polyps

• Leiomyomas

• Adenomyosis

• Uterine anomalies

• Endometrial thickening associated with hyperplasia and

malignancy

Evaluation of AUB Imaging Studies

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A quick word about uterine

fibroids…• Found in 70% of women by age 50

• 30% of women experience AUB

• The majority are asymptomatic and do not require

intervention

• Submucous fibroids that protrude into the uterine cavity

are most frequently related to AUB

• Women with intramural fibroids may also experience

AUB

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… And a quick word about

endometrial polyps…

• Localized hyperplastic overgrowths of endometrial tissue

that form a projection from the surface of the

endometrium

• Majority are benign (95%)

• May be asymptomatic

• Intermenstrual bleeding is the most frequent symptom

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A 42 year-old premenopausal woman has a

transvaginal ultrasound reporting a thick

endometrium measuring 15 mm.

Should this finding alone prompt concern about

endometrial hyperplasia or malignancy?

A. Yes

B. No

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Ultrasound endometrial

assessment

• The normal endometrium in a premenopausal woman varies in thickness according to the menstrual cycle

• 4 mm in the follicular phase

• Up to 16 mm in the luteal phase

• There is no standard threshold for abnormal endometrial thickness in premenopausal women

• Further evaluation should be based on the specific clinical situation

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When should endometrial

biopsy be considered?

• Age >40

• Risk factors for endometrial cancer

• Failure of medical treatment

• Significant intermenstrual bleeding

• Anovulatory menstrual cycles

(Level of evidence: II-2A)

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Endometrial cancer risk

factors• Age

• Average age 61 years

• 5%-30% of cases occur in premenopausal women

• Obesity (BMI >30 kg/m2)

• Nulliparity

• PCOS

• Diabetes

• HNPCC

• Lifetime risk for endometrial cancer 40-60%

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Differentiating ovulatory from

anovulatory menstrual cycles

• Anovulatory bleeding is more likely to be associated with

endometrial hyperplasia and malignancy

Ovulatory bleeding Anovulatory bleeding

• Regular menstrual cycles

• Associated with

premenstrual symptoms

and dysmenorrhea

• Irregular

• Heavy

• Prolonged

• Common near menarche

and the perimenopause

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Managing abnormal bleeding

in the perimenopausal patient

“…all women older than 45 years who

present with suspected anovulatory uterine

bleeding should be evaluated with

endometrial biopsy…”

- American College of Obstetricians and Gynecologists Practice

Bulletin No. 136, 2013

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Medical Treatment

• The first line therapeutic option

• Should be initiated once malignancy and significant

pelvic pathology have been ruled out

• Women found to be anemic from AUB should be started

on iron supplementation immediately

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Medical TreatmentEffective medical treatment options for abnormal uterine bleeding

Non-hormonal options Non-steroidal anti-inflammatory drugs (I-A)

Antifibrinolytics (I-A)

Hormonal options Combined hormonal contraceptives (I-A)

LNG-IUS (I-A)

Oral progestins

Depot-medroxyprogesterone acetate (I-A)

Danazol (I-C)

GnRH agonists (I-C)

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NSAIDs• Cochrane Review 2007:

• Reduction of menstrual blood loss by 33%-55% vs. placebo

• No significant difference in adverse effects

• Improvement in dysmenorrhea in up to 70% of patients

• Therapy ideally begins the day before menses and continues for 3-5

days or until bleeding ceases

• Clinical trials comparing NSAIDs to other medical agents have

found them to be less effective in reducing menstrual blood loss

Medical Treatment: Non-hormonal options

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Antifibrinolytics (tranexamic acid)

• Placebo-controlled trials: reduction in menstrual blood

loss 40%-59% from baseline

• Most commonly studied regimen: 1 g po q6h during

menstruation

• Single daily dose of 4 g also found to be effective

• Does not treat dysmenorrhea

• Controversy regarding possible elevated risk of venous

thromboembolism

Medical Treatment: Non-hormonal options

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Combined hormonal contraceptives

• Advantages:

• Cycle control

• Reduction of menstrual losses

• 40%-50%

• Improvement of dysmenorrhea

• Contraception

• Continuous use may offer superior effect

Medical Treatment: Hormonal options

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The levonorgestrel-releasing intrauterine system (LNG-IUS)

• Approved by Health Canada for treatment of heavy menstrual bleeding

• 70%-97% reduction in blood loss

• Amenorrhea in up to 80% at one year

• Other advantages:• Contraception

• Treatment of dysmenorrhea, pelvic pain due to endometriosis

• Cochrane Review 2006:

• LNG-IUS provides equivalent improvement in quality of life vs. surgical treatment options

Medical Treatment: Hormonal options

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A 14 year-old female presents to your office with

heavy, irregular menstrual periods. She has never

been sexually active. Is the levonorgestrel-releasing

intrauterine system a treatment option that may be

discussed with her?

A. Yes

B. No

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Oral progestins• A recognized treatment for anovulatory bleeding

• Cyclic progestins taken for 12-14 days each month

• 50% of women with irregular cycles will achieve menstrual

regularity

• Offer endometrial protection from effects of unopposed

estrogen

• Not an effective treatment for regular heavy menstrual

bleeding (I-E)

Medical Treatment: Hormonal options

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When is referral to

Gynecology indicated?• Acute presentation of AUB

• Severe iron-deficiency anemia

• Failure of conservative treatment

• Concern about possible malignancy

• Focal endometrial lesion

• Structural uterine abnormalities

• Endometrial biopsy indicated

• Desire for surgical treatment

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Summary• AUB is a common condition which has a significant

impact both at the individual level, and at the level of the

health care system

• Recommended investigations: CBC, BhCG, cervical

screening, cervical swabs

• TSH and coagulopathy screening if clinically indicated

• TVUS is the first-line imaging modality for AUB

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Summary• Endometrial biopsy should be considered in women >40

years or in those with bleeding not responsive to medical therapy

• Also in younger women with risk factors for endometrial cancer

• Medical treatment is the first-line therapeutic option

• Both non-hormonal and hormonal options may be considered

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Resources

• ACOG Practice Bulletin No. 128: Diagnosis of Abnormal

Uterine Bleeding in Reproductive-Aged Women. Obstetrics &

Gynecology, July 2012; 120 (1).

• ACOG Practice Bulletin No. 136: Management of Abnormal

Uterine Bleeding Associated with Ovulatory Dysfunction.

Obstetrics & Gynecology, July 2013; 122 (1).

• SOGC Clinical Practice Guideline No. 292: Abnormal Uterine

Bleeding in Pre-Menopausal Women. J Obstet Gynaecol Can,

May 2013; 35: S1-S28.

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Questions?